Get More Information

The CCM Opportunity

What is CCM?Recognizing the value Chronic Care Management (CCM) can deliver in improving health outcomes and reducing healthcare spending, the Centers for Medicare and Medicaid Services (CMS) adopted a new service code in January 2015. CPT Code 99490 reimburses physicians or other eligible healthcare professionals approximately $43 per patient per month (national average as of January 2017) for delivering at least 20 minutes of non face-to-face care coordination to eligible Medicare beneficiaries, with the following required elements:

Multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient

Chronic conditions place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline

How did the program change in 2017?The success of CPT 99490 and demand from healthcare providers prompted new codes and more reimbursements for 2017, expanding the CCM program and providing these additional revenue opportunities:

Add-on code G0506: A one-time code to reimburse providers (average $65.34) for extra time that wouldn’t have been part of the typical visit, but is required to initiate CCM services and create a comprehensive care plan for the patient.

CPT 99487 reimburses approximately $94 for 60 minutes of non-face-to-face care coordination and CPT 99489 reimburses approximately $47 for each additional 30 minutes.

Complex CCM shares common required service elements with CPT 99490 (now also referred to as non-complex CCM), but additionally requires the establishment or substantial revision of a comprehensive care plan, as well as moderate or high complexity medical decision making by the medical provider.

CareSync exceeds Medicare’s requirements for CCM with patient-centered engagement solutions for CPT 99490. We also support practices in maximizing the opportunities afforded by new complex CCM codes 99487 and 99489, and add-on code G0506. If complex care takes up more of your valuable time, why shouldn’t you be getting paid for the additional work it requires.

Getting Started with Chronic Care Management

Why should I use CareSync to provide this service? Can't I do it myself?You could do it yourself, but do you want to? CPT 99490 requires providing the full scope of services each and every month to every one of the patients in your CCM program. This means spending a minimum of 20 minutes per month per patient providing non face-to-face care coordination. Finding the time, human resources, and technology to meet the requirements is already difficult, but it has been our experience that it actually takes quite a bit more time to fulfill the requirements every month. And as evidenced by CMS expanding the time and reimbursements for complex CCM cases, you can see they acknowledged there were discrepancies in how much time it was going to take to provide the appropriate care.

Instead, why not partner with the leader in providing Chronic Care Management services to patients?

We follow your preferences and protocols.

We stay in contact with your patients, their families, and all their providers, keeping the lines of communication open and helping everyone get the most up-to-date and complete picture of the patient's health.

We make our clinical staff available to your patients 24/7/365.

We request medical records from all providers, and continue to do so every time there is a visit.

We translate the medical records (about 1/3 still come in via fax) into discrete fields and create reports (such as service reports and health summaries) that can be sent to or integrated into your EHR, or selected and downloaded as you choose.

We've already created a secure collaboration platform and reports that go beyond the CMS requirements.

Which patients/what chronic conditions are eligible?Eligible Medicare beneficiaries include those with:

Multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient

Chronic conditions place the patient at significant risk of death, acute exacerbation/decompensation

The Centers for Medicare & Medicaid Services maintains a Chronic Condition Warehouse with common chronic conditions listed to provide beneficiary, claims, and assessment data, but it did not limit the chronic conditions allowable under the CCM program. Chronic condition status is left to the discernment of the provider.

Which providers are eligible?According to CMS: “Physicians and the following non-physician practitioners may bill CCM services: Certified Nurse Midwives; Clinical Nurse Specialists; Nurse Practitioners; and Physician Assistants. CCM may be billed most frequently by primary care practitioners, although in certain circumstances specialty practitioners may provide and bill for CCM. The CCM service is not within the scope of practice of limited license physicians and practitioners such as clinical psychologists, podiatrists, or dentists, although practitioners may refer or consult with such physicians and practitioners to coordinate and manage care.”

While much of the time, primary care doctors coordinate care, there are plenty of eligible specialists who have taken on the role of CCM billing practitioner. For example, cardiologists are often the care coordinators for their patients with serious heart conditions.

Chronic Care Management Enrollment

Is a consent form required to enroll the patient?Previously, a signed consent form was required to enroll a patient in CCM. New rules from CMS for 2017 allow the provider to choose to obtain either a verbal or written consent, provided it is documented in the medical record and that a face-to-face visit has been completed within the last 12 months. Either way, the provider must do the following:

Inform the patient of the availability of CCM services; that only one practitioner can furnish and bill for these services during a calendar month; and that the patient has the right to stop the CCM services at any time (effective at the end of the calendar month).

Document in the patient’s medical record that the required information was explained and whether the beneficiary accepted or declined CCM services.

When can the patient be enrolled?Previously, CMS required the billing practitioner to furnish an Annual Wellness Visit (AWV), Initial Preventive Physical Examination (IPPE), or comprehensive evaluation and management visit to the patient prior to billing the CCM service, and to initiate the CCM service as part of this exam/visit. Now you can initiate CCM in the office or over the phone. Only new patients or patients who have not had a face-to-face visit within the past year are required to have an initiating visit for CCM services.

What if a patient is eligible, but doesn't have access to technology?If your patient has access to technology, a great advantage will be having mobile access to their care plan, health summary, medical records, and valuable healthcare tools through the CareSync app. They can use it online through the Internet or download it (from the Apple Store or Google Play) to their smartphone or tablet and take important health information with them wherever they go. However, patients do not have to use the CareSync app to experience their CareSync membership benefits. In fact, we have found many patients continue or increase their utilization of their existing practice portal to review their care plan and medical documents.

Everything we do at CareSync is designed to engage the entire family and care team. While we have found that most of our silver users love their iPads and other devices, and quickly master these tools, we don't require them to use tools they don't want to use. We talk to them over the phone. They love the personal attention and the fact that we check up on them and their health conditions. Additionally, if a patient doesn't have access to email or a mobile device, we can invite the appropriate caregiver and close the loop electronically or by phone with that person. Our Health Assistants coordinate care with the entire team on behalf of the patient, so the reports and data are accurate and effective, even if the patient doesn't personally engage.

What if a patient wants to discontinue the service or switch to another CCM provider?Only one provider may bill on any given month. The patient must notify CareSync in writing that they want to discontinue service, and the service will cease on the last day of that month.

CareSync Chronic Care Management Services

How does CareSync meet the Medicare requirements for CPT 99490?Here are the specific requirements, with the CareSync coverage of each:

24/7 Access to Clinical Staff. CareSync Health Assistants are available 24 hours per day, 7 days per week, via phone, email, and in-app messaging. This provides a distinct advantage over call services. Additionally, we have EHR access and follow provider preferences and protocols to ensure we direct patients according to the provider’s wishes.

Care Management. When the provider creates an Assessment and Plan, Health Assistants will obtain the information to create tasks, medication and measurement reminders, and more important information in a format that the patient and care team can easily understand and engage. The information is completed and updated to the provider, who is able to adjust the care plan according to documented results. A complete, current list of all conditions, medications, allergies, and more are always available to every provider via a free CareSync account, and pushed monthly via Blue Button and other methods to ensure the information is easily available at the point of care and that all providers have reconciled data.

Care Plan. A comprehensive Care Plan is created with the required elements: Problem list, expected outcome and prognosis, measurable treatment goals, symptom management, planned interventions, medication management, community/social services ordered, coordination of other agency and specialist services, etc. We also help identify preventive care needs that are aligned with MACRA quality measures. To accomplish this, CareSync Health Specialists retrieve information needed from the patient, the patient's care team, and the Assessment and Plan gathered from each of the patient's active providers. The comprehensive health information is always available to every member of the patient's care team, as each provider and family member is offered a free CareSync account.

Care Transitions. CareSync Health Assistants refer patients to other clinicians in a timely manner, retrieve the records from each visit associated with the trigger event, update the patient's information, and share it with every member of the care team. We are always available 24/7/365 in case the patient goes to the hospital or ER, and we are there to help support them and notify the provider in a timely manner.

Coordination with Other Providers. Every visit with the primary care team as well as home- and community-based providers is recorded, the Care Plan is updated, and each provider has access to the documentation via the free CareSync application and pushed updates. If the Plan includes a referral to another provider or service, all the providers can view the activity associated with it.

Patient and Caregiver Access (Asynchronous). CareSync was created with the idea that caregivers are often the best source of information about the patient. The revolutionary ability for families to interact with the information, share information before the visits, and respond to notifications when a reminder is missed ensures that CareSync caregivers have the best possible opportunity to facilitate patient care and give the provider a new level of useful data. Caregivers get email and device notifications and activity summaries, and are encouraged to interact with the patient and Health Assistants via in-app comments and notes.

Does CareSync do anything beyond Medicare's requirements?We're glad you asked! These are just a few:

Timeline. Our trademarked Health Timeline™ is an important part of the patient's history and the care team's understanding of what has been done lately. The most recent 30 days of timeline activity can be included at your request with the monthly update to all current providers.

Caregiver Accounts. The patient's family members and other caregivers not only have access to the patient's information, but are also encouraged to create their own accounts so they are truly engaged with the application.

Medication and Measurement Reminders. Medication and measurement instructions are part of every Care Plan, but CareSync turns it into an engaging opportunity for patients to participate in their care through patient-generated data and complete the communication loop with the providers. Medication reminders with push notifications, as well as measurement device integrations are leveraged.

Visit Planning Tools. Many patients forget what they were going to ask the doctor at a visit, and even more forget what they were told. Patients and caregivers are encouraged to plan the visit by adding notes and tasks that are transmitted to the provider before the visit. A voice recorder built into the app allows the doctor's explanations and instructions to be saved to the visit and are immediately available to the entire care team.

Medical Records. In order to review the patient's Assessments and Plans, the Health Assistants get actual medical records from each of the current providers, and records for any visit while the patient is a CCM plan member. The records include SOAP notes, images, lab results, and anything associated with the visit.

Is your staff trained in HIPAA compliance?Yes! Privacy and security are a key concern at CareSync. Everyone on the CareSync team is required to complete ongoing mandatory HIPAA and privacy training and everyone has signed the required HIPAA agreements.

Is CareSync a certified EHR?CareSync is a collaborative, family-centered Personal Health Record. We use the same databases that certified EHRs use to create useful information from all the records we get - even the data from paper records is hand-keyed into discrete data fields. CMS requires that a certified EHR is used by the billing provider, so we will get a copy of your EHR's certification, and all the data will be available for you to receive into your EHR.

How do you comply with the CMS electronic communication requirements?To be a third party provider of CCM, you have to have a level of integration, technology, and physician oversight. As a technology and care coordination company, CareSync has the technology and work process capabilities to integrate CCM workflows within practice operations, and can act as a true extension of the practice. We go beyond the minimum requirements to make sure each provider has access to all the information in a way that works best for the practice. The Care Plan and Health Summary are available digitally through EHR integration, automated or on-demand Blue Button download, or direct mail. We provide digital access to the patient's providers and caregivers with complimentary access to the CareSync platform, and any member of the care team can also request a fax or paper copy of the digital Care Plan. Click for more information on our Blue Button feature.

Chronic Care Management Code Restrictions

Is there a time when a patient covered by CCM is not eligible for the service?Yes. As sourced from CMS documentation as of June 2017, billing restrictions include:

CCM cannot be billed during the same service period as codes G0181/G0182 (home healthcare supervision/hospice care supervision), or CPT codes 90951–90970 (certain End-Stage Renal Disease services)

CCM should not be reported for services furnished during the 30-day Transitional Care Management service period (CPT 99495, 99496)

Complex CCM and prolonged Evaluation and Management (E/M) services cannot be reported the same calendar month

Consult CPT instructions for additional codes that cannot be billed concurrent with CCM

There may be additional restrictions on billing for practitioners participating in a CMS sponsored model or demonstration program (for example, Medicare will not make duplicative payments for the same or similar services for patients with chronic conditions already paid for under the CPC+ initiative)

Time that is reported under or counted toward the reporting of a CCM service code cannot also be counted toward any other billed code

What if I have a patient in one of the above situations, such as a Transitional Care Management period?You can't bill Chornic Care Management services during the 30-day TCM period, but our service capabilities can help you meet the TCM requirements, including the 30-day care coordination required period.

Chronic Care Management Billing Details

What are the required elements for billing CPT 99490?"Chronic care management services, at least 20 minutes of clinical staff time directed by a physician or other qualified healthcare professional, per calendar month, with the following required elements: multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient; chronic conditions place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline; comprehensive care plan established, implemented, revised, or monitored." (Source: The Centers for Medicare & Medicaid Services, current as of 1/5/17)

What insurance plans will pay CPT 99490?Traditional Medicare, select Medicare Advantage plans, and a growing number of commercial and Medicaid plans. Many secondary insurers also contribute to the patient responsibility.

What is the expected payment?The average reimbursement is about $43 (national average as of January 2017). The payment amount is subject to geographical adjustments, but you can get a good idea of what your reimbursement in your area will be with the CareSync Revenue Calculator. Click here, choose your region, and add your eligible Medicare lives estimate for your practice.

How are the care coordination minutes tracked?CareSync care coordination technology tracks the minutes for each patient-related activity we perform, and the totals are included in your monthly billing report. Note: Every patient-related billable event is tracked and the timed events are available in case of an audit.

Is my patient responsible for any payment?The same as any other billable code under Medicare, the patient is responsible for deductibles, copayments, and remainder amounts according to the patient's insurance agreement. CPT 99490 and complex Chronic Care Management codes are not exempt from cost-sharing rules unfortunately, so Medicare Part B patients with no secondary coverage will be responsible for about $8/month, but keep in mind that it does vary. The intent of the code is to reduce costs for all parties, including the patient. Better care coordination means fewer visits, which in turn reduces the patient's overall out-of-pocket expenses.